Self-Referral Form
Personal Details
Title
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Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name
Last/Family Name
Date of Birth
Gender
Male
Female
Other
Address Line 1
Address Line 2
Town/City
County
Postcode
Permission to send letters to your home address
Yes
No
Mobile Number
Permission to contact by text
Yes
No
Permission to leave voicemail
Yes
No
Other Number
Permission to leave voicemail
Yes
No
E-mail
Permission to send email?
Yes
No
Do you need an interpreter?
Yes
No
If yes, please specify your language
Ethnicity
Please select
White - A White British
White - B White Irish
White - C3 Other White
Mixed - D White and Black Caribbean
Mixed - E White and Black African
Mixed - F White and Asian
Mixed - GF Other mixed or mixed unspecified
Asian or Asian British - H Indian
Asian or Asian British - J Pakistani
Asian or Asian British - K Bangladeshi
Asian or Asian British - LK Other Asian or Asian unspecified
Black or Black British - M Caribbean
Black or Black British - N Other African or African unspecified
Black or Black British - PE Other Black or Black unspecified
Other Ethnic Groups - R Chinese
Other Ethnic Groups - SE Any other group
Unwilling to disclose - Z not stated
Sexuality
Heterosexual
Lesbian or gay
Bisexual
Other
Do not wish to say
Are you pregnant or have you had a baby within the past 12 months?
Yes
No
Do you work for the NHS? (for example an NHS Trust, primary care or a charity funded by primary care, CCG etc)
Yes
No
Do you work in Social Care (for example you work for the local authority, in a care home or providing care for residents at home?)
Yes
No
GP Details
GP Practice
Please select
ACORN SURGERY, 136 MEETING HOUSE LANE
ALBION STREET GROUP PRACTICE, 87 ALBION STREET
AVICENNA HEALTH CENTRE, DR R KADHIM, 2 VERNEY WAY
AYLESBURY PARTNERSHIP
BERMONDSEY AND LANSDOWNE MEDICAL MISSION
BERMONDSEY SPA MEDICAL CENTRE, EYOT HOUSE, 50 OLD JAMAICA ROAD
BLACKFRIARS MEDICAL PRACTICE, 45 COLOMBO STREET
BOROUGH MEDICAL CENTRE, DR KK MISRA, LORNAMEAD HOUSE
BOROUGH MEDICAL CENTRE, DR R SHARMA, LORNAMEAD HOUSE
CAMBERWELL GREEN SURGERY, 17 CAMBERWELL GREEN
CONCORDIA PARKSIDE, 52 CAMBERWELL GREEN
DMC CHADWICK ROAD, 60 CHADWICK ROAD
DMC, 163-169 CRYSTAL PALACE RD
MADDOCK WAY, DR RHK SINHA, 10 MADDOCK WAY
EAST STREET SURGERY, 301 EAST STREET, WALWORTH
ELM LODGE SURGERY, 2 BURBAGE ROAD
FALMOUTH ROAD GROUP PRACTICE, 78 FALMOUTH ROAD
FOREST HILL GROUP PRACTICE, 1 FOREST HILL ROAD
GRANGE ROAD PRACTICE, BERMONDSEY HEALTH CENTRE
HAMBLEDEN CLINIC, BLANCHEDOWNE
LISTER PRIMARY CARE CENTRE, DR ARUMUGARAASAH, 101 PECKHAM ROAD
LISTER PRIMARY CARE CENTRE, HURLEY CLINIC
LISTER PRIMARY CARE CENTRE, DR SMS HOSSAIN, 101 PECKHAM ROAD
LORDSHIP LANE SURGERY, 417 LORDSHIP LANE
MANOR PLACE SURGERY, 1 MANOR PLACE
MELBOURNE GROVE MED. PRAC, MELBOURNE GROVE
NEW MILL STREET SURGERY, 1 WOLSELEY STREET
NUNHEAD SURGERY, 58 NUNHEAD GROVE
OLD KENT ROAD SURGERY, 182-184 OLD KENT ROAD
PARK MEDICAL CENTRE, 57 HAWKSTONE ROAD
PENROSE SURGERY, 33 PENROSE STREET
PRINCESS STREET GROUP PRACTICE, 2 PRINCESS STREET
QUEENS RD SURGERY, 12 QUEENS ROAD
SILVERLOCK, 2-3 WARNDON STREET
SIR JOHN KIRK CLOSE SURGERY, 3 SIR JOHN KIRK CLOSE
ST GILES SURGERY, DR PATEL, 40 ST.GILES ROAD
ST GILES SURGERY, DRS VIRJI & BEGLEY, 40 ST.GILES ROAD
ST JAMES CHURCH SURGERY, NORTH AISLE,THURLAND ROAD
STERNHALL LANE SURGERY, 12 STERNHALL LANE
SURREY DOCKS HEALTH CENTRE, 12-13 BLONDIN WAY, OFF DOWNTOWN ROAD
TESSA JOWELL HEALTH CENTRE
THE GARDENS SURGERY, THE GARDENS
THREE ZERO SIX MEDICAL CENTRE, 306 LORDSHIP LANE
TRAFALGAR SURGERY, 10 TRAFALGAR AVENUE
VILLA STREET MEDICAL CENTRE, 47 VILLA STREET
GP not listed (free text box)
If you have selected "GP not listed", please can you provide details of your GP here:
Permission to inform GP of referral and outcome of referral
Yes
No
Further Information
Use this space for any specific requests, e.g. about how we contact you, or any disabilities we should be aware of.
Where did you hear about us?
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Recommended by my GP practice
Recommended by King’s, St Thomas’s or Guy’s
Leaflet picked up at my GP practice
Leaflet picked up from hospital clinics at King’s, St Thomas’s or Guy’s
Other services in South London and Maudsley Trust
Friends/Family
Internet search
Twitter
Millwall Football Site
Community organisation, please specify in the free text box below
Other, please specify in the free text box below
I am a health professional making a referral on behalf of the patient
Recommended to Compass from GP
Recommended to Compass from hospital
If you have selected Community organisation or Other in the previous question, please specify details here:
If you have selected 'I am a health professional making a referral on behalf of the patient', please write your name, email address and telephone number here:
If you have selected 'Recommended to Compass from hospital', please let us know which hospital service:
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